Evidence Base for Positioning Electroconvulsive Therapy and Magnetic Seizure Therapy in Treatment Guidelines for Major Depressive Disorder

Major depressive disorder (MDD) is characterized in a substantial proportion of patients by an inadequate response to standard pharmacological and psychotherapeutic interventions, thereby increasing the need for more rapid and potent biological treatments. In this context, convulsive neuromodulation therapies play a central clinical role, particularly in severe, psychotic, treatment-resistant, or life-threatening depressive states. Electroconvulsive therapy (ECT) is regarded as one of the most effective biological interventions for the treatment of MDD, supported by decades of clinical experience and high-level evidence. Magnetic seizure therapy (MST), by contrast, aims to exert antidepressant effects through convulsive mechanisms similar to those of ECT and has attracted increasing interest due to its more focal cortical stimulation and its potential to offer a more favorable cognitive adverse-effect profile. In this review, ECT and MST in MDD are examined comparatively in light of the current evidence, with acute efficacy, cognitive safety, and use in special patient populations evaluated within an integrated framework. While the acute antidepressant efficacy and clinical predictability of ECT are supported at the highest level, MST appears to be a promising yet still experimental option, particularly in selected cases in which cognitive safety is prioritized. This review aims to clarify the position of ECT and MST within treatment algorithms for MDD and to support clinical decision-making.